What look like playground injuries to one physician, may be suspected child abuse to another. A Penn State College of Medicine study reports that there is widespread inconsistency among pediatricians in how they interpret their responsibility to report suspected child abuse. Mandated reporting of child abuse has been in effect for 30 years and requires that people who interact with children in a professional capacity contact child protection services whenever they have "reasonable suspicion" that a child has been abused. Though it has been assumed that mandated reporting statutes regarding child abuse are self-explanatory, this is the first systematic investigation to examine how mandated reporters – in this study, pediatricians – actually interpret and apply the threshold for mandated reporting.

"We found that physicians have different interpretations and different thresholds for when ’reasonable suspicion’ exists," said Benjamin H. Levi, M.D., Ph.D., professor of pediatrics and humanities, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center. "There will always be subjectivity involved. But if pediatricians are applying the reporting guidelines in vastly different ways, this has profound implications for the children who may or may not be victims of abuse, as well as families and caregivers who are subject to inconsistent standards."

The study, released today (July 5, 2005), was published in the July 1 online edition of Pediatrics, a journal of the American Academy of Pediatrics (AAP). Co-authored by Georgia Brown, R.N., B.S.N., the article is titled "Reasonable Suspicion: A Study of Pennsylvania Pediatricians Regarding Child Abuse."

Levi and Brown developed a survey that included two frameworks to measure the degree of likelihood needed for suspicion of child abuse to rise to the level of "reasonable suspicion." The survey was sent to all 2,051 members of the Pennsylvania chapter of the AAP. Sixty-one percent, or 1,249, responded. Data were compiled by the Penn State Survey Research Center.

On a rank order scale of one to 10, (with one being most likely diagnosis and 10 the least likely), physicians were asked how high suspected child abuse would have to rank before they felt it amounted to reasonable suspicion. Twelve percent of respondents indicated that "abuse" would have to rank one or two to qualify as reasonable suspicion. Forty-one percent set the threshold at three or four, and 47 percent stated that abuse could rank as low as five to ten on the scale, suggesting that for some, any suspicion at all warranted reporting to child protection services.

Using another measurement scale, the same physicians were asked how likely suspected child abuse would have to be before it amounted to reasonable suspicion. Fifteen percent of respondents indicated that abuse would need to be greater than 75 percent likely before reasonable suspicion existed. Twenty-five percent stated that a 60 percent to 70 percent likelihood was needed, 25 percent identified the necessary likelihood as 40 percent to 50 percent, and 35 percent set the threshold as low as 10 percent to 35 percent.

"Not only was there wide variation regardless of physician age, training, or years of experience, but when we compared the individual responses for the two scales, 85 percent were internally inconsistent, meaning that the physicians answered differently depending on the scale used. This is alarming because this suggests there is no consistency in how the majority of physicians surveyed interpret the threshold for when to report suspected abuse," Levi said. "I think we took it for granted that the concept of reasonable suspicion was clear to everyone, but our data show that it in fact has a wide range of meanings not only between physicians, but within the same physician."

Levi and Brown plan to more broadly administer their survey to see if the current results are generalizable to other mandated reporters such as nurses, teachers, daycare providers, etc.

"Child abuse is obviously a critical social issue and more studies are needed to determine whether these findings are applicable to the greater population of mandated reporters," Levi said. "If we do find that there is widespread confusion about what constitutes reasonable suspicion across classes of mandated reporters, it will require rethinking what society should expect from mandated reporters, what sort of training and guidelines may be needed to meet the expectations, and what will determine our societal threshold for reporting possible child abuse."

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